The feeling that you are not really there is a fairly common experience, and it is likely to be one of two things, although the number of potential causes of those things is quite large. Most of the time, feelings of "derealization", which the description of these experiences most suggests, or the sensation of "depersonalization", which is the other explanation that is related and slightly less likely, are due to anxiety, depression, sleep disorder or sleep deprivation or the effects of drugs or alcohol. These feelings may also be an indication of migraine, epilepsy, various other neurological illnesses, some disorders of the inner ear or several different psychiatric conditions. There are usually other symptoms going on when these are responsible for such perceptions and experiences, however, and there are a number of ways of stopping or treating them.
Derealization, an alteration in one's experience of the external world so that it seems different or unreal, can occur in up to 5 per cent of people during their lifetimes, and affects between 30 and 65 per cent of people at the time of a traumatic event or experience. It involves the sensation of being separated from the material world and perceiving things and people differently than before, often with feelings of unusual familiarity or unfamiliarity and without the usual vividness or emotional correlates with which these things are experienced. This is thought to be due to some disconnection or abnormal connection between the occipital lobes, that are involved in visual perception, and parts of the temporal lobes that are responsible for recognition, memory and proper decoding and understanding of what is being experienced. People experiencing this often see external reality as a movie or TV show, or feel that they are a third person watching what is going on, and cannot process information and act on it as they ordinarily do. This can aggravate the feelings, and there is often the sense that something seriously wrong is happening, which creates anxiety and arousal that can make matters worse.
The other major cause of dream-like distortion and unreality of this kind is depersonalization. This is a disorder of self-awareness more than perception of the external world, and people often report that their behaviors, emotions and sensations do not belong to them, and their memory of what they do and what they experience during these episodes may be hazy. The medical and neurological conditions that can cause depersonalization are very much like those responsible for derealization, and anxiety and panic disorders, dissociative disorders and schizophrenia can also have these symptoms, as well as obsessive-compulsive disorders. Severe stress, overuse of cannabis and the short-term effects of amphetamine, caffeine, alcohol and nicotine can be responsible, and depersonalization is particularly associated with addiction to benzodiazepines and other sleep medications, and with withdrawal from many drugs.
Epilepsy and particularly temporal lobe epilepsy, migraine and particularly the migraine prodrome or that form of the disorder called "confusional migraine" or head injury that is severe enough to disturb brain function but not severe enough to cause unconsciousness are among the main neurological causes. Disorders of the vestibular system that connects the inner ear and the brain, responsible for the perception of balance and motion and the maintenance of equilibrium, can cause feelings of derealization. These may be experienced in mild form in an airplane or on a roller coaster, and may relect a sudden surge in arousal and stress transmitters such as adrenaline and noradrenaline, because throughout evolution sudden disequilibrium of this kind has usually been associated with falling off a cliff or other fatal events.
Anxiety disorders, personality disorders, bipolar disorder, schizophrenia and sometimes depression can have these symptoms, and there is a psychiatric condition known as dissociative disorder in which these kinds of episodes happen repeatedly. Sleep disorders can also have this effect. This list is not meant to be frightening: the likelihood of a brain tumor or other neurological disorder is low in people who do not have neurological symptoms or a past or family history of these conditions. Anxiety usually manifests itself in other ways, too, and people with mood or thinking disorders will usually have other symptoms involving the moods, thoughts or perceptions.
The effects of drugs, alcohol, stimulants and other aspects of lifestyle are prominent causes of these feelings. Derealization can occur with frequent or heavy cannabis use, and can also be caused by alcohol overuse or alcohol withdrawal alcohol; withdrawal from benzodiazepines like Valium or Xanax can have this effect, and psychedelic drugs like LSD or Ecstasy can do this also. Caffeine and nicotine in significant amount have been associated with derealization, too. Prolonged sleep deprivation even without a clinical sleep disorder has given rise to derealization, and many people may feel this way a little even with jet lag or staying up late and getting up early.
A primary-care physician may not always be able to make a specific diagnosis but could be helpful in identifying past head injury, suggestions of migraine, balance disorder or seizure disorder that warrant neurological inquiry or other symptoms of anxiety, mood disorder or other psychiatric condition that may be readily treatable. The best way to identify potentially causative lifestyle factors or substance use is to try a period of time without caffeine, stop smoking and discontinue the use of marijuana if these are issues and try a strict Benjamin Franklin schedule of sleeping at night and being up during the day if sleep deprivation could be present.
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